Why can't I have a pump?

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JonathanGi

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I have been told that can't have a pump after 57 years of injecting because I am too well controlled. Any persuasive tips I can try?
 
Hi @JoanthanGI

Sorry to hear that you have been refused a pump.
Are they determining the quality of your control just on HbA1c or are you using a sensor and have they looked at Time in Range. Many clinics focus a lot more on TIR now that this data is available.
Does your ‘good control’ involve a lot of hypos? If so, and this causes you stress that can be an argument for a pump.
If you have regular night time hypos, these could be another reason, as the pump will allow you adjust the basal to suit what you need hour by hour.

I am not sure about this, and will tag @everydayupsanddowns but I thought that the most recent guidelines simply having Type1 should give you access to pump therapy.
 
In your position, I would think about why I want a pump? Whilst it is a later technology than injecting, it is not necessarily easier.
How is injecting to maintain your level of control impacting your quality of life?
Are you constantly topping up basal with bolus insulin to deal with different basal needs at different times of the day?
How would the ability to temporarily suspend basal help your life?
Do you need very small doses?

I love my pump but it is definitely not a silver bullet, it still needs a fair amount of effort, adjusting basal patterns, more accurately carb counting, remembering what activities need a temporary increase of basal and what needs a temporary decrease ... and by how much.

I don't mean to put you off getting a pump but you need to be able to articulate how it would improve the quality of your life to justify it.
 
After 57 years of being a Type 1 diabetic I do have to inject myself quite frequently. I don't seem able to inject any more than 5 units at a time. I seem to have had quite a change in the way I manage since cancer treatment. I don't have any problems with hyperlipodystrophy but I think I must be injecting into muscle on occasions as I have lost muscle since I have got older (I am 66). I take plenty of exercise and today could be a good example of how I might find a pump of benefit. I planned a 12 mile run and I woke up to a BG of 2.9. The cortisol effect kicked in and within an hour BG was 7.6. For me this is too high to start running but I had my usual long acting and half a unit of short acting before starting. Within the first mile my sensor alarmed me (set to 9.3) but I continued and by mile 10 (an hour and a half later) BG had dropped to 3.7. I had 5g of carb at this point. 2 miles later I was home and had 2.5 units of insulin and 25g of carbohydrate. An hour later BG was 8.9 and going up. I have very few hypos. I would like to think that a pump might make managing this regime slightly easier. I also run regularly with a GP who finds it hard to believe after all these years that I don't qualify for a pump. I am very tightly controlled - HbA1c of 37 (slightly better than the 34 that it was previously).
 
JonathanGi said:
I planned a 12 mile run and I woke up to a BG of 2.9. The cortisol effect kicked in and within an hour BG was 7.6. For me this is too high to start running but I had my usual long acting and half a unit of short acting before starting. Within the first mile my sensor alarmed me (set to 9.3) but I continued and by mile 10 (an hour and a half later) BG had dropped to 3.7. I had 5g of carb at this point. 2 miles later I was home and had 2.5 units of insulin and 25g of carbohydrate. An hour later BG was 8.9 and going up. I have very few hypos. I would like to think that a pump might make managing this regime slightly easier. I also run regularly with a GP who finds it hard to believe after all these years that I don't qualify for a pump. I am very tightly controlled - HbA1c of 37 (slightly better than the 34 that it was previously).
Click to expand...

How are you defining hypos @JonathanGi ?

Do you worry about them? Do they sneak up on you (eg happen unpredictably overnight)? Do you have workarounds in your routine to try to avoid them (eg running deliberately high at times just in case your levels unpredictably drop?

Pumps access in England is underpinned by NICE TA151. The two criteria are having (or worrying about) unpredictable hypos in attempting to reach your target HbA1c. And having an HbA1c above target.

1 Recommendations | Continuous subcutaneous insulin infusion for the treatment of diabetes mellitus | Guidance | NICE

www.nice.org.uk www.nice.org.uk

“ attempts to achieve target haemoglobin A1c (HbA1c) levels with multiple daily injections (MDIs) result in the person experiencing disabling hypoglycaemia. For the purpose of this guidance, disabling hypoglycaemia is defined as the repeated and unpredictable occurrence of hypoglycaemia that results in persistent anxiety about recurrence and is associated with a significant adverse effect on quality of life“

To get an HbA1c of 37 does suggest excellent diabetes management, but I wonder what proportion of time you spend below 4.0mmol/L, and how much you worry about that, a d about retaining your warning signs. Your Libre2 (assuming that was what gave you the alarm) should have a report of ‘time in range’.

There are recommendations for limiting the amount of time spent below 4.0 to as low as possible. See this thread:

International consensus recommendations for Time in Range

If your HbA1c is on target, and you don’t have many hypos, or don’t worry about them - then you don’t qualify under NICE guidance. But from what you wrote above you have 2 hypos in a day, and one was overnight (so may have lasted for some time).

According to TA151, it would all boil down to your experience of hypos really.
 
I define a hypo as a blood glucose of less than 4. This is not the same as a reading from my Libre which measures interstitial glucose. I still get very good hypo signs, even after 57 years. I never run deliberately high as I would feel nauseous. Runsweet is a very good website. Running with a high BG will increase BG still further. BG also depends on the type of running I do. Parkrun, for example, over a very short distance nearly always puts BG up. I try to start Parkrun at less than 5 but I know 24 minutes later it's likely to be over 10. Slow warm down helps a bit to decrease but I usually have more insulin than usual. I don't eat before. If someone could tell me how to prevent this spike I'd be happy! Slower running over a much longer distance tends to put BG down.Time in target over the last 90 days has been 89%.
I'm not going to get a pump!
Thanks for your reply and interest.
 
JonathanGi said:
After 57 years of being a Type 1 diabetic I do have to inject myself quite frequently. I don't seem able to inject any more than 5 units at a time. I seem to have had quite a change in the way I manage since cancer treatment. I don't have any problems with hyperlipodystrophy but I think I must be injecting into muscle on occasions as I have lost muscle since I have got older (I am 66). I take plenty of exercise and today could be a good example of how I might find a pump of benefit. I planned a 12 mile run and I woke up to a BG of 2.9. The cortisol effect kicked in and within an hour BG was 7.6. For me this is too high to start running but I had my usual long acting and half a unit of short acting before starting. Within the first mile my sensor alarmed me (set to 9.3) but I continued and by mile 10 (an hour and a half later) BG had dropped to 3.7. I had 5g of carb at this point. 2 miles later I was home and had 2.5 units of insulin and 25g of carbohydrate. An hour later BG was 8.9 and going up. I have very few hypos. I would like to think that a pump might make managing this regime slightly easier. I also run regularly with a GP who finds it hard to believe after all these years that I don't qualify for a pump. I am very tightly controlled - HbA1c of 37 (slightly better than the 34 that it was previously).
Click to expand...

Unless guidelines have changed having to inject over & above what is considered normal is a reason for pump funding, that is how I got mine but its good few years back now.
 
Appointment with endocrinology dept is looming. What pump is easiest to use? I have lots of scars on my abdomen after cancer treatment. Any pump thoughts, experiences and general advice?
 
You don’t have to use your abdomen for cannula sites @JonathanGi I don’t. I use my thighs and occasionally the top of my bottom.

I find my pump very easy to use. It’s loopable, but I don’t loop with it. It’s a Dana i pump, and is the second Dana pump I’ve had.
 
Is it possible just to use arm(s) only? How much insulin can go into these things?
 
JonathanGi said:
Is it possible just to use arm(s) only? How much insulin can go into these things?
Click to expand...

My pump takes 300 units, some take less. I tried my arms but I’m quite slim so they didn’t work well.

Mine’s a tubed pump and I’ve always chosen tubed pumps (been pumping more than 20 years). I like the choice of cannulas. This means I can change to a different kind if I find a body area needs it. My pump is controlled by my phone, which is very convenient too.

Do you know which pumps are available at your clinic?
 
Does that mean you have to take a phone with you all the time? If pump only lasts 3 days I won't need anywhere near 300 units. 20 years is a lot of experience! Thanks for your very swift response. I may have other foolish questions after I have been for a run. I am also reasonably skinny and have lost a lot of muscle as I have aged.
 
No, I don’t have to take a phone. I can use the pump itself to do things too. I don’t change the pump reservoir every 3 days. I change the cannula on Day 3, then on Day 6 I change the reservoir, tubing and cannula. You can put as much or as little insulin in the reservoir as you want up to a max of 300 units.
 
This is my pump. Advanced Therapeutics supply it in the U.K. but it’s made by Sooil, the manufacturer of the first commercially available insulin pump. You can see the pump screen and buttons in the pictures and also a shot of the phone app. If you wanted to, you could use the pump itself 100% of the time and never use the app, but I use both, eg I use my phone to bolus when out for a meal:

DANA i Insulin Pump – Advanced Therapeutics (UK) Ltd

advancedtherapeutics.org.uk advancedtherapeutics.org.uk

.
 
JonathanGi said:
Does that mean you have to take a phone with you all the time? If pump only lasts 3 days I won't need anywhere near 300 units. 20 years is a lot of experience! Thanks for your very swift response. I may have other foolish questions after I have been for a run. I am also reasonably skinny and have lost a lot of muscle as I have aged.
Click to expand...
It depends upon the pump.
Most pumps only store 200 units and you don't have to fully fill them. I tend to fill mine to about 100 units for three days.

Regarding using the phone, again, this depends upon the pump, Most tubed pumps will allow you to control it on the pump but patch pumps will need some kind of "remote control". That said, you only need to do this when you need a bolus or if you want to stop/reduce the basal. The pump will continue to give you insulin without any need for a "controller" as the pump has the "brains".

These are all good questions but they as pumps tend to vary, it is best to find out which pumps your clinic offers. Most clinics offer more than one and will give you a chance to do some research and chose.
 
JonathanGi said:
Is it possible just to use arm(s) only? How much insulin can go into these things?
Click to expand...

I think arms are more often used by Pod users (and other patch pump options). Have you checked Omnipod 5? That might be an option for you?
 
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